For More Information about KidZone contact Laura Talisman, KidZone
Director at [email protected] or 713- 551-7231
KIDZONE 2016-2017 APPLICATION
AFTER SCHOOL CARE
Evelyn Rubenstein Jewish Community Center of Houston
 Male  Female
Child’s First Name
Birthday
Child’s Last Name
Age
Grade 2016-17
Street Address
City
Zip Code
Elementary School
School Phone #
School Dismissal Time
Parent/Guardian #1 Information
Parent/Guardian #2 Information
Parent 1 Name (Last, First)
Parent 2 Name (Last, First)
Parent 1 Residence Address (Street, City, Zip)
Parent 2 Residence Address (Street, City, Zip)
Parent 1 Email
Parent 2 Email
Parent 1 Home Phone
Parent 2 Home Phone
Parent 1 Business Phone
Parent 1 Cell Phone
Ext.
Parent 2 Business Phone
Parent 2 Cell Phone
Who will be the primary person to contact for your child?
e
Name
e
Name
Phone #
Ext.
Emergency Contact #1 Information
Emergency Contact #2 Information
Emergency Contact #1 Name (Last, First)
Emergency Contact #2 (Last, First)
EC #1 Relationship to Child
EC #2 Relationship to Child
EC #1 Residence Address (Street, City, Zip)
EC #2 Residence Address (Street, City, Zip)
EC #1 Home Phone
EC #2 Home Phone
EC #1 Cell Phone
EC # 2 Cell Phone
Doctor’s Name
Phone
My Child May be released to the following:
Name:
_
Relationship to Child:
Phone # (Cell):
Name:
Relationship to Child:
Phone # (Cell):
_
Check Appropriate Boxes
KidZone
(includes transportation)
 5 day
 4 day
 3 day
 2 day
 1 day
Transportation Only
 5 day
 4 day
 3 day
 2 day
 1 day
Vacation Camp Package

Jewish Holiday Package

 Fall Semester
 Spring Semester
 Entire Year
Please read carefully before signing:
1. Center membership must be maintained current, and no balances due
throughout school year.
2. All balances are payable in advance.
3. I give permission for my child to take part in all activities, and in the
event of an emergency, I give my consent for the J staff to act for me
according to their best judgment.
4. I give my permission for my child’s picture to be used for the J
marketing. (To refuse this permission, you must cross out this sentence
only)
5. Participation in any JCC activities and use of any recreational facilities
involves a risk of accidental injury despite all safety precautions. Having
been informed of the activities to be conducted by the Evelyn
Rubenstein Jewish Community Center of Houston, I/we, as an individual
or as a parent or guardian of the participant named herein, assume all
risk and hazards incidental to the activities, and release from
responsibility and agree to indemnify and hold harmless The Evelyn
Rubenstein Jewish Community Center of Houston, its officers, directors,
independent contractors, volunteers and all employees.
6. I understand and except the late fee of $1 per minute after 6:00PM.
7. I understand and agree to call the J by 1:30PM if my child will not be
attending KidZone or riding the bus.
I have read the above. I understand the J’s policy on registration and agree to
be responsible for payment of all fees due to the J. I understand that failure to
make payment as required will result in termination of service.
Parent or guardian signature
Date
Enclose a deposit of $150 per child. There will be a $200 cancellation fee required for all families
that do not fulfill their registered commitment to the program.
Payment arrangements for entire year/semester are due prior to start of program
To register or for more information contact Laura Talisman:
713-551-7231 or [email protected]
If your child will be taking classes during the upcoming semester please let us know what class,
day and time so we can make sure they make it on time.
Monday Class:
Time:
Tuesday Class:
Time:
Wednesday Class:
Time:
Thursday Class:
Time:
Friday Class:
Time: